Complications of Chemotherapy

1
Complications of Chemotherapy

• Discuss post-chemotherapy complications and their
  management
• Chemotherapy can have wide-ranging effects on
  patients
• Human body amazing at what it can tolerate

2
What is chemotherapy?

• Treatment with drugs that kill cancer cells (or
  make them less active)
• Interfering with tumour cells ability to grow and
  proliferate
• Adjuvant chemotherapy ie localized breast cancer
• Induction chemotherapy ie AML
• Curative chemotherapy ie Diffuse Large B Cell
  Lymphoma
• Palliative chemotherapy

3
Categories of Chemotherapy

• Antibiotic derivedanthracyclines, bleomycin
• Plant Alkaloidsperiwinkle plant--vincristine,
  paclitaxel
• Alkylatorscylcophosphamide
• Antimetabolitesinterfere with synthesis of
  nucleic acids-5FU, Methotrexate
• Epipodophyllotoxinsinhibit topoisomerase
  2--etoposide
• Anti-hormonaltamoxifen, coritcosteroids
• TYROSINE KINASE INHIBITORS--GLEEVEC
• MONOCLONAL ANTIBODIESTARGETED therapy

4
Complications of Chemotherapy

• SHORT TERM
• Fever
• Nausea
• Infusional reactions
• Oral complications
• Diarrhea
• Anemia
• Neuropathy
• Alopecia
• Rash, Extravasation
• Emotional

5
FEBRILE NEUTROPENIA

• On Chemotherapy, 7 to 14 days post chemo
• WBC nadir, NEUTROPHILS are 1st line of DEFENCE
• Temperature great than or equal to 38.3 degrees
  centigrade
• Absolute Neutrophil count (ANC) less than 1.0
• One of the few Oncologic EMERGENCIES

6
FEBRILE NEUTROPENIA

• History, Physical
• Focus on possible source of infection
• Respiratory tract, urine, skin, gi tract
• CBC, LFT,CR
• CXR

7
FEBRILE NEUTROPENIA

• Draw cultures from 2 different sites, urine C/S
• 50 of cultures positive
• 65 positive cultures are gram positive organisms
• Broad Spectrum antibiotics
• If well, hemodynamically stable
• CIPRO and CLAVULIN PO and home

8
FEBRILE NEUTROPENIA

• IF UNWELL
• ADMIT WITH BROAD SPECTRUM IV ANTIOBIOTICS IE
  TAZOCIN OR IMIPENEM OR AMP AND GENT
• WITH NEUPOGEN SUPPORT( 300mcg sc daily until anc
  gt1.0), IV FLUIDS ETC.

9
FEBRILE NEUTROPENIA

• Usually fever lasts less than 48 hours
• If fever longer than 48 hrs, patient needs IV
  antibiotics, consider antifungals
• Usually bacterial or viral infections but fungal
  infections becoming more of an issue
• As WBC and ANC recover, patient usually improves
• NB special situation for Acute Leukemics, PICC
  lines

10
FEBRILE NEUTROPENIA

• Clinical consideration and follow-up very
  important, especially if patient discharged home

11
NAUSEA

• Most chemotherapeutic agents cause nausea
• Why?
• systemically as drug makes its way to nausea
  centre of brain (chemotherapeutic trigger zone)
• Sight and smell of drug

12
Neuronal pathways involved with chemotherapy- and
radiotherapy-induced nausea and vomiting
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NAUSEA

• Types of Nausea
• Anticipatoryconditioned reflex to sight and
  smell of chemotherapy area
• Acutewithin 24hrs and related to
  chemotherapeutic agents
• Delayedmore than 24 hrs. post chemotherapy--speci
  fic agentscisplatin, cyclophosphamide, adriamycin

14
NAUSEA

• Worst offenders
• Cisplatin
• High dose cyclophosphamide
• Doxorubicin, eprirubicin, carboplatin also have a
  high incidence of nausea

15
NAUSEA TREATMENT

• Medications
• Prochlorperazine (stemetil)
• Metoclopramide (maxeran)
• Ondansetron (Zofran)5HT3 antagonists
• Dexamethasone
• Lorazepam, Haloperidol
• Aprepitant

16
Drug treatment of chemotherapy- and
radiotherapy-induced nausea and vomiting
17
NAUSEA TREATMENT

• Relaxation
• Varying foods, meals

18
INFUSIONAL REACTIONS

• Very common with new MONOCLONAL ANTIBODY agents
  ie RITUXIMAB
• Infusion of these agents may take several hours
• Fever, hypotension, asthmatic like reactions,
  pain
• Premedicate or treat with Dexamthasone, Benadryl,
  Tylenol
• May have to stop infusion temporarily
• If serious, may have to discontinue agent

19
Oral Complications

• Occurs in approx 40 of patients receiving
  chemotherapy
• Very common
• Team approach using nutritionist, nursing,
  dentist, pain management team
• Oral hygiene important-soft tooth brushes, floss?
• Source of bacteremia

20
Oral Complications

• loss of taste
• Affects appetite, nutrition
• Which in turn affects healing
• In this situation, we advise patients to think of
  eating as a job
• Sometimes, oral complications require nutrition
  supplements or alternatives

21
MUCOSITIS

• Chemotherapy is intended to injure rapidly
  dividing cells such as the MUCOSA
• Presents with mouth sores, inflammation,
  sometimes sloughing of mucosa anywhere in the
  GASTROINTESTINAL TRACT, RESP TRACT
• Usually occurs in the mouth

22
MUCOSITIS

• SIMPLE ORAL MUCOSITIS TREATED WITH MOUTH RINSE
• MAGIC MOUTHWASH
• SALT WATER GARGLES
• TOPICAL ANALGESIA ie Xylocaine viscous, tantum
• Systemic analgesia
• NYSTATIN

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MUCOSITIS

• Upper gi tract
• Heartburn
• Very common
• Antacid, Ranitidine, Pantoloc

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MUCOSITIS

• SEVERE MUCOSITIS
• GI TRACT
• DIARRHEA, SLOUGHING OF MUCOSA, ESOPHAGITIS
• ADMISSION, TNA, BOWEL REST, OTHER SUPPORTIVE
  MEASURES
• 5FU ONE OF THE MAIN CULPRITS

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DIARRHEA

• VERY COMMON, approx 45. USUALLY A FEW DAYS AND
  SELF-LIMITING

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DIARRHEA

• Risk factors
• Elderly
• Known colitis
• GI tumour
• 5FU, irinotecan
• Concomitant irradiation

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DIARRHEA

• InfectionCDIFF or other
• Laxatives, other medications (stool softeners)
• Of course, usually the chemotherapy is the
  culprit.

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DIARRHEA

• Usually self-limiting
• Hydrationpo, IV if more SERIOUS
• Dietfluids, BRAT (Bananas, Rice, Apples, Toast)
• Loperamide (immediately if on Irinotecan)
• 4mg followed by 2mg Q4H or until formed stool.
  Up to 16 mg per day
• Usually rule out CDIFF first

29
DIARRHEA

• If severe, Ocreotide (Sandostatin)
• Decreases fluid output from bowel
• 100mcg sc TID
• Growth hormone analogue-decreases all salivary
  gland secretions
• And Antibiotics may be considered espec if CDIFF
  positive
• oral metronidazole or oral vancomycin
• oral CIPRO

30
ANEMIA

• Bone marrow suppression from chemotherapeutic
  agents
• Secondary to malignancy
• Anemia work-up

31
ANEMIA

• Chemotherapy induced anemia
• Erythropoietin, Aranesp
• Stimulate marrow to produce RBCs
• Used while on chemotherapy only
• Additional iron po vs. iv
• Sc injection

32
ANEMIA

• Adverse effects of Erythropoietin
• Flu-like illness
• Rashes
• Diarrhea
• Headache
• Bone pain
• Liver, kidney
• Vascular event FOLLOW HEMOGLOBIN

33
ANEMIA

• Dosage Eprex 40,000 units sc qweekly Aranesp
  150mcg sc qweeklyto 7 days)

34
NEUROPATHY

• Very common with vincristine, vinblastine,
  cisplatin
• Usually temporary.
• Sometimes leads to dose alterations or stopping
  of some drugs

35
NEUROPATHY

• Most commonly, we see numbness and tingling in
  fingers and toes
• Can you do up your buttons?
• Is numbness becoming more proximal?
• May need to alter chemotherapeutic agents or
  doses thereof

36
Emotional effects of chemotherapy

• Malignant diagnosis can be overwhelming
• The discussion of treatments and adverse effects
  can also be overwhelming
• Anxiety, depression, fatigue related to diagnosis
  and treatments
• LOTS of information regarding treatments

37
Emotional effects of chemotherapy

• Gaining Control by giving up control. Dr. B.
  Rotella
• daily routine goes upside down
• Changing work routinemissing work for weeks,
  months
• Income changes

38
Emotional effects of chemotherapy

• The inability to forget is infinitely more
  devastating than the inability to remember.
  Mark Twain
• Hard to forget some of the stressful times one
  goes through
• Battle fatigue

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Emotional effects of chemotherapy

• It always seems impossible until its done.
  Nelson Mandela
• Getting through months of chemotherapy is very,
  very difficult
• People are amazing though.
• The human condition is to battle

40
Emotional effects of chemotherapy

• Things to do today Exhale, Inhale, Exhale.
  Buddha
• Just surviving each day step by step
• Team approach social worker, supportive care
  coordinators, pastoral care, pharmacy

41
Complications of Chemotherapy

• Longterm
• Cardiac
• Secondary Malignancies
• Fatigue
• Neuropathy
• Arthropathy

42
Cardiac Complications

• Adriamycin or other anthracyclines
• 450mg per m2 dose lifetime
• Strong treatment for breast cancer and
  hematologic malignancies
• Affects myocardium longterm above maximum dose

43
Secondary Malignancies

• Skin cancers
• Breast cancers
• Hematologic Malignancies

44
Fatigue

• Thorough history, physical exam and ancillary
  tests
• Fatigue workshop

45
Arthropathy

• Post monoclonal antibodies
• Treated in usual fashion with NSAIDs, prednisone

46
GLEEVEC

• Oral chemotherapy for Chronic Myeloid Leukemia
• Molecular model of chemotherapeutic treatments,
  tyrosine kinase inhibitor
• Philadelphia Chromosome produces abnormal
  protein, BCR-ABL
• Gleevec stops the signal of the BCR-ABL protein,
  therefore halting Leukemogenesis
• Fluid retention, diarrhea, nausea, fatigue, abdo
  pain, muscle cramps, bone pain